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Dr Marie Sartain
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Most physicians unable to estimate patients’ out-of-pocket costs: How pharmacists can help

By Sonya Collins

An estimated one in three Americans struggles to afford their medical bills. Who do they go to for help finding solutions to this common problem? “My physician” is the typical answer. But according to a recent study published in JAMA, few are equipped to help.

Researchers surveyed 371 physicians in primary care, gastroenterology, and rheumatology. Given a summary of a patient’s health insurance benefits, the physicians were asked to estimate the patient’s out-of-pocket costs for a medication that costs $1,000 per month without insurance.

The task required survey participants to calculate the patient’s costs at 4 different points in time throughout the year based on 4 types of cost-sharing: deductibles, co-pays, co-insurance, and out-of-pocket maximum.

Only one in five physicians accurately estimated the hypothetical patient’s out-of-pocket costs. The vast majority of the doctors, the study suggested, cannot tell patients what to expect when they pick up their prescriptions. As many patients may not know the price of their medications with certainty until they reach the pharmacy counter, pharmacists—rather than physicians—may need to step in to help them find more affordable options when needed.

The researchers concluded that physicians need more transparent drug-pricing information in order to have informed conversations about costs with their patients.

“We know that the correct data exist, so why don’t physicians have access to it when they are prescribing these medications?” asked Robert Popovian, PharmD, a pharmaceutical economist and Chief Science Policy Officer for Global Healthy Living Foundation.

E-prescribing platforms, such as SureScripts, have monetized accurate drug-pricing information on the pharmacy side. This same information is less accessible on the prescribing side, Popovian said. While electronic health records may provide prescribers with patient formulary and benefit information, nearly 80% of physicians say they don’t trust this information and that details regarding patients’ out-of-pocket costs are rarely, if ever, available, according to CoverMyMeds’ Medication Access Report.

The JAMA study highlights a clear need for accurate drug-pricing information at the point of prescribing. But, until that becomes a reality, pharmacists may be called on to play a larger role in identifying cost-saving solutions for patients who cannot afford their medications as prescribed.

The first step a pharmacist can take when a patient cannot pay for their prescription, Popovian said, is to call the prescriber.

“I think that’s their fiduciary responsibility as a patient provider. Pharmacists should pick up the phone and call the physician and say, ‘The alternative is for you to prescribe something different, and this is my recommendation,’” Popovian said.

“More often than not, there are alternatives out there and pharmacists need to be more proactive about getting them to patients.”

When changing the prescription is not an option, pharmacists have other tools available to them.

But exploring cost-saving options for patients can be extremely time-consuming.

For the full article, please visit for the March 2022 issue of Pharmacy Today.

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